Can Nurse Practitioners Text Patient Care Orders?

Have you ever texted about a patient? In the emergency department where I work, texting can be an easy way to consult with a specialist or send an image of a patient's X-ray, lab results or even chief complaint. But, is this legal? What are the implications of texting about patient care?

Although texting has become the preferred means for communicating in this generation, the rules on whether or not we as nurse practitioners can utilize the feature to discuss patients with other members of our healthcare team are hard to keep track of; especially when it comes to sending patient care orders via text.

In May 2016, the Joint Commission (the nation’s oldest and largest standards-setting and accrediting body in healthcare) released a statement in support of providers sending patient care orders via text so long as the orders were transmitted over a secure system. But within a few months of releasing its statement, due to a growing concern among healthcare organizations over security issues, the Joint Commission delayed the implementation of texting patient orders to research the matter further.

Ultimately, the Joint Commission reversed its position in December 2016 and recommended that providers be prohibited from texting patient care orders regardless of whether a secure system is used to transmit the message. The Center for Medicare & Medicaid Services (CMS), which worked in conjunction with the Joint Commission on its decision, recently released a Survey and Certification Memorandum to reiterate and clarify its position, giving further insight on why texting patient care orders is not permissible.

As part of its purpose, CMS oversees many Federal healthcare programs including those that involve health information technology such as electronic health records. CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that healthcare organizations must meet in order to begin and continue participating in Medicare and Medicaid programs. The CoPs and CfCs apply to numerous types of healthcare organizations including ambulatory surgical centers, FQHCs, home health agencies, hospices, hospitals, rural health clinics and long-term care facilities (just to name a very few).

The memo released by the CMS is pretty straightforward, stating that its stance is due to the fact thatthe practice of texting orders is not compliant with the Conditions. Given the informal nature of that text messages tend to communicate, it’s fairly easy to understand how texting orders directly conflicts with the Conditions.

For example, the Conditions of Participation for Medical Records state that a hospital must maintain a medical record for each inpatient and outpatient that is accurately written, promptly completed, properly filed and retained and accessible. The conditions also state that medical records must document evidence of all practitioners’ orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. Medical records must also be retained in their original or legally reproduced form for a period of at least five year and additionally, the hospital must have a procedure for ensuring the confidentiality of patient records; using a system of author identification and record maintenance that maintains the integrity of the authentication and protects the security of all record entries. Offhand text messages sent from personal cell phones don't comply with these guidelines.

Not only is texting orders not compliant with the CoPs and CfCs’ as outlined in the memo, but another major concern, as the Joint Commission highlighted, is that using text messages as a method for transmitting orders will increase the burden on nurses, as they would be responsible for manually transcribing them into the patient’s electronic health record (EHR). Because texting is not integrated into the EHR system, the more detailed an order becomes, the more necessary a verbal conversation becomes to avoid errors and crucial information being overlooked by the individual entering the order.

Similarly, texting orders does not allow for real-time clarification and confirmation like a verbal order would. The individual entering the order would have to text the provider and then await their response. The inability to directly ask questions and obtain confirmation right away raises safety concerns for the patient, especially if there is possibility of a clinical decision support alert during the order entry process.

Both the Joint Commission and the CMS agree that computerized provider order entry (CPOE) is the preferred method as they allow providers to directly enter orders into the EHR electronically; although handwritten and verbal orders are still acceptable.

Although texting patient care orders is prohibited, the CMS does recognize that texting is a beneficial means for healthcare employees to communicate with one another and thus does allow healthcare providers to text patient information, so long as it’s done through a secure platform. This helps ensure compliance with the CoPs and CfCs, as well as HIPAA regulations for protecting the patient’s privacy and confidentiality.